Working with Themes in

Trauma Narrative &

Cognitive Processing

Susan Schmidt, PhDElena Doskey, PhD

Special thanks to Dr. Cohen and Dr. Kliethermes for the development

of and permission to use multiple slides in this presentation.

Judith Cohen, M.D.Allegheny Health Network

Matthew Kliethermes, Ph.D.Children’s Advocacy Services of Greater St. Louis at

University of Missouri, St. Louis

Complex PTSD in TF-CBT: Moving Beyond Gradual Exposure

What Drives Complex PTSD?

• Multiple incidents of trauma• Multiple interpersonal trauma types• Prolonged trauma exposure across multiple

developmental stages

These experiences may contribute to: • Higher levels of affective dysregulation• Personal desensitization to trauma history• Changes to core beliefs about self, others, world• Interpersonal difficulties

What’s a theme?

View from the Literary World

• Definition: – The underlying message of a story– Critical belief about life conveyed in the story – What the story means– Stories often have more than one theme.

• Function: – Bind together essential elements of a story– Provide understanding of the “character’s” experiences– Give key insight into how the author views the world/life

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View from Trauma-Focused Therapy

• A “stable and coherent framework for understanding one’s experience” is an important psychological need for trauma survivors (McCann & Pearlman, 1990).

• Processing themes is an attempt to help meet that need.• Processing themes requires looking for meaning across

traumas rather than within one trauma.

• The meaning ascribed to a trauma often changes following exposure to subsequent traumas.

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Theme Of Self Of Others/WorldTrust I make bad decisions. I can’t

trust my own judgement.

People can’t be trusted. Don’t trust the system; authority.

Control/Power I don’t have control of future. Control is all or nothing. Must control what I can.

Life is unpredictable, uncontrollable.

Esteem I am a bad kid. I am worthless. I am only valuable for….

People are bad, will hurt you.

Intimacy I shouldn’t get close to people.

Others will take advantage of me. Relationships cause pain.

Safety I am unsafe. Something bad will happen to me….

Adults won’t keep me safe. Adults are dangerous.

Common Trauma Themes

Identifying Trauma ThemesThroughout treatment, listen and watch for clues on how trauma has

impacted child’s (and caregivers) beliefs about self, others, world.

(Possible) Trauma Theme

Client’s history of trauma experience &

relationships

Client statements in therapy and at home: through initial and on-going assessment; in session; through TN –What the child says

Client behaviors/interactions

in session –What the child does

Pattern of client behaviors/interactions

with others –As reported by child

or caregiver

INCORPORATING THEMES INTO

TRAUMA NARRATION

Trauma Narration Continuum

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Complex Posttraumatic Stress

PTSD

Thematic Trauma

Narrative

Allows youth to reflect on themes of their life and how their trauma history has shaped their views of themself, others and the world.

Will likely address specific incident(s) within larger thematic context.

Gradual exposure to traumatic memories will include exploration of overarching messages learned across traumatic incidents.

Identify, Organize, and Process Complex Trauma Themes

Events• Desensitization• Behavioral/Emotional• Focus on the “Trees”• Who, what, when, where,

how?

Themes• Meaning Making• Cognitive/Emotional• Focus on the “Forest”• Why?

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• Visualize trauma narration and processing as a continuum.• Adjust your location on this continuum based on the

individual needs of the client.• TN may include a combination of event-specific “chapters”

and thematic “chapters.”

Traditional TN and/or Thematic Narrative?

• What is the major source of distress?• Where are the PTSD symptoms

clustering?• Repeated or complex traumatic

experiences?

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2 or More Symptoms• Irritable or angry

outbursts • Reckless/

self-destructive• Hypervigilance• Exaggerated startle

response• Problems

concentrating• Sleep disturbance

DSM-5Posttraumatic Stress Disorder

EArousal &Reactivity

CAvoidance

BIntrusion Symptoms

1-2 Symptoms• Recurrent intrusive

thoughts/images• Dissociative reactions/

flashbacks• Recurrent distressing

dreams (may be general scary content in children)

• Trauma re-enactment play in young children

• Distress to internal or external traumareminders

1-2 Symptoms• Avoid memories,

thoughts/ feelings of event (internal reminders)

• Avoid (or try to) people/places objects/ situations (external reminders)

DNegative

Cognitions orMood

2 or More Symptoms• Inability to remember

aspects of trauma • Persistent/exaggerated

negative beliefs of self, others, world

• Distorted thoughts re: cause or outcomes

• Persistent negative emotional state

• Diminished activities interests

• Detached/estranged• Can’t experience

positive emotions

USE OF A TIMELINE TO DEVELOP THE

THEMATIC PATHWAY

Identify, Organize, and Process Complex Trauma Themes: Getting Started

TIMELINE:–Facilitates “forest level” processing…, –…but also supports “tree level”

processing–Visual nature of timeline makes themes

more accessible for many youth.

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Types of Timelines

Sequencing of eventsTime periodsThematic timeline

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DEVELOPING THEMATIC

NARRATIVES

Considerations

• The thematic narrative is still gradual exposure

• Collateral information + timeline = effective narrative

• A thematic narrative ≠ a disorganized, free-for-all narrative

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Questions to Build Thematic Narrative

• Regarding a specific person…– “Tell me about ______. Tell me about the best

time you had with ______. Tell me about the worst time you had with ______.”

– “What does this person believe about you?”– “What do you believe about yourself because of

your relationship with ______?”– “What do you believe about ______ because your

relationship with ______?”

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Questions to Build Thematic Narrative

• Regarding a specific theme...– “What does ______ mean to you? What does it

look like?”– “Tell me about some times in the past when you

have felt ______. Tell me about some times in the past when you haven’t felt ______.”

– “What does your idea of ______ look like moving forward?”

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Cognitive Processing of Trauma Themes

Cognitive Processing

• Beliefs about myself• Beliefs about others• Beliefs about the world• Maximization of control through

balanced thoughts• Be organized and intentional

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Cognitive Processing Challenges

• Thinking errors cause us to take a too extreme position in relation to client’s schemas

• Failure to appreciate differences in development of beliefs between complex and acute trauma:– Beliefs informed by multiple traumas not just one– Beliefs developed over extended periods of time– Often no pre-existing “healthy” belief– May be a higher degree of objective validity to their

beliefs– Beliefs are more thematic (e.g., I’m worthless) than

event-specific (e.g., I shouldn’t have worn that skirt).

Cognitive Processing with Complex Trauma: Balanced Thinking

– There is often truth to both sides of a debate– Validates the client– Helps avoid cognitive processing power

struggles– Trauma can be easily conceptualized as an

event that disrupts balance– Facilitates meaning making

The Importance of Balanced Thinking

SafetyI’m never safe---------------------------------------------------I’m always safe

All people are dangerous-------------------------------------All people are safe

The world is not safe-------------------------------------The world is safe

TrustI can’t trust myself at all-----------------------I trust myself completely

I can’t trust anyone--------------------------------------I trust everybody

IntimacyI can’t be close to anyone-------------------Everyone is my best friend

Power/ControlI’m always weak------------------------------------------I’m always strong

It’s all my fault----------------------------Nothing is my fault

EsteemI’m worthless-------------------------------------------------I’m perfect

The Importance of Balanced Thinking

Balanced Thoughts

• Unbalanced: “I’m useless. I can’t do anything right.”

• Balanced: “I’m not happy with where my life is, and I am working hard to improve.”

• Unbalanced: “I can’t show any weakness; people will hurt me!”

• Balanced: “Sometimes it is a bad idea to show weakness, butthere are some people I can trust to not hurt me when I cry.”

What is the spirit of cognitive processing?

Collaborative New belief must be realistic and helpful

Truth to both sides of a debate Avoid taking polar opposite view of client, often this is inaccurate,

unhealthy as well Avoid power struggle – Not trying to prove client wrong

Maintain focus… Therapist guides through open ended Socratic questioning

Changing beliefs is an effortful process & requires practice/repetition

Empowering client to evaluate own beliefs

Validation is Critical in Cognitive Processing

• Complex trauma survivors are often highly sensitive to perceived invalidation/disrespect.– Done poorly, cognitive processing can easily be

perceived as invalidating.

• Practice validating beliefs. – For example, how would you validate:

“I’m a worthless piece of crap; nobody likes me.”

Cognitive Processing: Useful Strategies

Make the process explicit (a parallel process)– Identify the problematic belief– Identify what you want to say, but DON’T say it– Validate the belief– Develop understanding of the belief– Help the youth/caregiver become aware of how the belief

might be a problem– Identify a potential balanced belief– Identify the information they are not paying attention to– Help them attend to this information (Socratic process)– Make the process explicit

Cognitive Processing: Step-by-Step

Validation

• Validate current belief & connect to trauma experiences

• Using the Cognitive Triangle: Identify how belief might be a problem (rate belief; rate connected feelings, identify behaviors)

• Obtain permission to evaluate

Cognitive Processing Techniques

• More helpful way to think about it? • Examining the evidence, including conducting behavioral experiments• Lists and Definitions• Best friend role-play• Responsibility Pie• Acting “as if”• Scaling questions• Metaphors/Stories

Re-evaluate

• Summarize new information gained and make a new triangle• Rate new belief and connected feelings – new triangle• Ask which triangle is more helpful – old one with old thought or

new one with new thought• Home assignment (e.g. try out new beliefs daily, rating feelings

with new belief until next session)

Cognitive Processing: The Nuts and Bolts

• Identify the belief the client has shared or that is apparent in the work you have completed– “I am the only one who can protect myself.”– Frame the beliefs positively

• Identify how much the client endorses that belief– “On a scale of 0-10, 0 being you absolutely don’t

believe it and 10 being you believe it with every part of you, how much do you believe this statement?”

• Identify how much the client endorses that the belief is helpful– “On a scale of 0-10, 0 being completely unhelpful and

10 being the most helpful believe ever, how helpful is this belief?”

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Cognitive Processing: The Nuts and Bolts

• Solicit evidence for the rating– “How come you believe this at a _____? What would

it take for you to believe it more/less?”• Present counter evidence as needed• Ask client to reexamine the evidence and come

up with a more balanced thought– Provide a frame for the new belief and have client fill

in the rest– “In the past, I have needed to protect myself and now,

_____________________________.”• Re-rate the new belief

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Cognitive Processing Skills

Responsibility Pie/Circle

Most often used for “my fault” thoughts:• Ask the client to draw a circle. Write the thought above the circle. • Ask client to come up with a list of everyone or everything that is

responsible• Have the client divide the pie, showing by size the proportion of

responsibility• Use Socratic questions to understand reasoning for pie slice sizes• Gently challenge unhelpful/faulty reasoning• When more helpful/accurate thoughts emerge, have client draw

new circle with new divisions• Ask client to come up with a new, more helpful thought based on

the activity

Examining the Evidence-Preparation

• The sexual abuse happened because I finally said “yes”.– Did he say ok, fine when you said No? What did he say, do?– Who was older, him or you? Who was bigger? – What were some reasons you trusted him at first?– Can you give consent legally?

• I can never be happy because sexual abuse happened.– What made you happy before? Which of those things still make you happy?– When you think about future, how do you fee, what do you look forward to?– Are there things you’ve done since SA/times you’ve been happy? Tell me about

them.– How do you know when you’re happy? What’s it look like? What does it feel like in

your body?

ListsExample: “Your thought is, ‘I am a bad kid.’ Let’s make a list of things kids do that are good. Tell me what you think of when you think about what a kid does that is good.”

• Have client generate a list of actions kids do that are helpful, constructive, and positive

• Ask the client which of these actions they ever done or could do. • Write down the list of actions the child owns • Based on the list and identified personal actions, have the child come

up new, more helpful thoughts such as: I help my brother with his homework I help with chores sometimes I do some good things so I am a good kid

Lists and Definitions

Ask client to define words AND/OR make lists• DEFINITION: “You said you cannot trust anyone. Let’s define

‘trust’ tell me what trust means to you.” (Write down trust characteristics)

• LIST: “One thought that is difficult for you is thinking “I am a terrible mom”. Let’s make a list of good things that mom’s do for their children. These can be big things but they can also be small, everyday kinds of things.”

DefinitionsExample: “I can’t trust anyone.”

• Have the child (or caregiver) define what trust means. What actions or behaviors indicate that people could be trustworthy?

• Have the child (or caregiver) generate a list of people they know or knew who could be trusted even for the little things, even some of the time.

• Now – ask the child or caregiver if they have a new, more helpful thought about trust. A more helpful thought might be, “I can trust some people for some things.”

Implications for Conjoint

• Less of a product/1-time event and more of an ongoing discussion/process.

• Sharing of evolution of beliefs about self, others, and the world during the trauma and now through treatment.

• Opportunity for youth and caregiver(s) to partner together to challenge problematic beliefs.

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Working with Themes in Trauma Narrative & Cognitive ProcessingSpecial thanks to Dr. Cohen and Dr. Kliethermes for the development of and permission to use multiple slides in this presentation.Complex PTSD in TF-CBT: Moving Beyond Gradual ExposureWhat Drives Complex PTSD?What’s a theme? View from the Literary WorldView from Trauma-Focused TherapySlide Number 8Slide Number 9Identifying Trauma ThemesIncorporating Themes Into Trauma Narration Slide Number 12Trauma Narration Continuum�Thematic Trauma NarrativeIdentify, Organize, and Process Complex Trauma ThemesTraditional TN and/or Thematic Narrative?Slide Number 17Use of a Timeline to Develop the Thematic PathwayIdentify, Organize, and Process Complex Trauma Themes: Getting StartedTypes of TimelinesDeveloping Thematic Narratives ConsiderationsQuestions to Build Thematic NarrativeQuestions to Build Thematic NarrativeCognitive Processing of Trauma ThemesCognitive ProcessingCognitive Processing ChallengesCognitive Processing with Complex Trauma: Balanced ThinkingThe Importance of Balanced ThinkingThe Importance of Balanced ThinkingBalanced ThoughtsWhat is the spirit of cognitive processing?Validation is Critical in Cognitive ProcessingCognitive Processing: �Useful StrategiesCognitive Processing: Step-by-StepCognitive Processing: The Nuts and BoltsCognitive Processing: The Nuts and BoltsCognitive Processing SkillsResponsibility Pie/CircleExamining the Evidence- PreparationListsLists and DefinitionsDefinitionsImplications for Conjoint